ORIGINAL ARTICLE   

Italian Journal of Vascular and Endovascular Surgery 2024 December;31(4):188-94

DOI: 10.23736/S1824-4777.24.01688-7

Copyright © 2024 EDIZIONI MINERVA MEDICA

lingua: Inglese

Surgical treatment of nutcracker syndrome

Julia PAOLINI ^{1, 2} ✉, Nunzio MONTELIONE ¹, Vincenzo CATANESE ¹, Franco A. CODISPOTI ¹, Alessandro CIOLLI ¹, Francesco SPINELLI ¹, Francesco STILO ¹

¹ Unit of Vascular Surgery, Campus Bio-Medico University Hospital, Rome, Italy; ² Unit of Vascular Surgery, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy

BACKGROUND: Nutcracker syndrome (NCS), also known as left renal vein entrapment syndrome, represent a rare vascular disorder characterized by the compression the left renal vein (LRV) between the abdominal aorta and the superior mesenteric artery resulting in downstream dilation of the LRV resulting in symptoms such as hematuria, chronic debilitating left flank pain, proteinuria, fatigue, headaches and pelvic congestion. NCS is frequently misdiagnosed and its true prevalence remains uncertain.
METHODS: This monocentric study presents a retrospective analysis of the short- and medium-term outcomes of surgical treatment in patients with NCS, treated between January 2019 and May 2024. Six patients (five male and one female, with a mean age of 26.5 years) underwent left renal vein (LRV) caudal transposition to the inferior vena cava via a median mini-laparotomy and transperitoneal approach. Clinical evaluation, ultrasound imaging and radiological tests was performed to identify left renal vein compression in the angle between superior mesenteric artery and abdominal aorta. The primary outcomes were mortality and reintervention rates at 30 days and during follow-up. Secondary outcomes included the duration of the procedure, blood loss, the need for blood transfusions, intensive care unit (ICU) stay, and length of hospitalization.
RESULTS: No early complications were observed within 30 days postoperatively. At an average follow-up of 15 months, the re-intervention rate was 16.7%: only one patient complained persistent hematuria three months after the procedure. In this case, a venoplasty patch on the previously transposed LRV was performed, resulting in symptom resolution. The average operative duration was 176 minutes (range: 142-220 min), with a mean blood loss of 205 mL (range: 100-400 mL). None of the patients required ICU admission or blood transfusion. The average hospital stay was 3.6 days (range: 3-5 days).
CONCLUSIONS: The surgical treatment of NCS with left renal vein transposition has proven to be a safe and effective procedure, yielding favorable short- and medium-term outcomes.

KEY WORDS: Renal nutcracker syndrome; Hematuria; Transposition of great vessels